Nursing Grand Rounds Point of Care Scholars: Filling the Gaps in - - PDF document

7/24/2014 1 Nursing Grand Rounds

Point of Care Scholars: Filling the Gaps in Evidence with Research

Christin Zwolski DPT, PT, OCS Deborah Williams RN, CNOR Jennifer Bekins MS, CCC-SLP

Discuss newly discovered gaps in nursing and allied health research evidence.

Objective

The Importance of Evidence-Based Practice

• Improves outcomes for children,

families and our organization

• Upholds Standards of Professional

Practice

• Supports core Magnet principles

7/24/2014 2 Organizational Outcomes

• Safety
• Care Integration
• Community Health
• Productivity
• Cost
• Clinical Expansion
• Reach
• Research
• Innovation

Accelerating our way forward through improvement, innovation and partnerships

Vision: To be the leader in improving child health

Drive strategic & sustainable growth Decrease cost continuously Develop essential & transformative capabilities

2015 Strategic Plan

5

National Patient Safety Goals

• Hospital
• Critical Access Hospital
• Behavioral Health Care
• Ambulatory Care
• Home Care

7/24/2014 3 Standards of Practice

Professional Organizations

• Magnet Model Components

Magnet Model Component

• New Knowledge, Innovations and

Improvement

7/24/2014 4

Injury Prevention for Adolescent Female Soccer Players at Risk of Noncontact Anterior Cruciate Ligament Injury

Christin Zwolski, PT, DPT, OCS Orthopedic and Sports Medicine Physical Therapy

Objectives

• To gain increased awareness of the need for

injury prevention interventions in a population

• f young female soccer players at the highest

risk of sustaining a noncontact anterior cruciate ligament (ACL) injury.

• To explore and evaluate the current literature

for evidence regarding injury prevention interventions

• To discover the injury prevention efforts put

forth by Cincinnati Children’s Medical Hospital Center’s Soccer Outreach Program

Background

• Why target young

female soccer players?

7/24/2014 5

High Risk Population Lack of Intervention High Medical Costs Decreased Quality of Life

Clinical Question P: Among adolescent female soccer players I: Does education alone C: vs. education plus high-risk screening

and/or injury prevention training

O: Decrease the number of noncontact ACL

injuries?

7/24/2014 6 Search Strategy

Keywords

• Soccer, football, injury, prevention, education,

adolescent, female, player, athlete, anterior cruciate ligament, knee Databases

• PubMed, CINAHL, SPORTDiscus, PEDro
• Date last search completed: 11/21/2013

Synthesis of the Evidence on ACL Injury Prevention

• Efficacy: Mixed results
• Best type, frequency, and delivery: Lack
• f consensus
• None of the articles directly addressed

the PICO question

7/24/2014 7

There is insufficient evidence and a lack of consensus to make a recommendation…

Educational Intervention

Implementation

• Planned research study involving educational

intervention in a population of adolescent female soccer players.

• Aim 1: To determine the extent of ACL injury

prevention knowledge gained and retained from an educational intervention program among female adolescent soccer players aged 12-18.

• Aim 2: To investigate the effects of an educational

intervention on the incidence of noncontact ACL injuries in female adolescent soccer players aged 12-18.

7/24/2014 8

Evaluation

• Pre- and post-test

assessments of injury prevention knowledge

• Number of noncontact

ACL injuries sustained following intervention

In the meantime… Thank You!

Christin Zwolski, PT, DPT, OCS Christin.zwolski@cchmc.org

7/24/2014 9 Reducing Sharps Injuries in the OR, Are We Using the Evidence?

presented by: Deborah R. Williams RN II, CNOR Liberty Perioperative Services

Objectives

• To relate impact of Federal legislature known as the

“Needlestick Safety and Prevention Act of 2000” on the reduction of sharps injuries

• To explore evidence regarding reduction of sharps injuries in the
• perating room (OR) setting
• To define top three recommended practices in reducing sharps

injuries in the OR

• To describe IRB proposal created to compare perforation rates

when using single or double gloving technique

Clinical Issue

Federal legislature known as the Needlestick Safety and Prevention Act of 2000 brought about a drastic reduction of sharps injuries in the medical community overall, yet the incidence in the operating room actually saw an increase. The Needlestick Safety and Prevention Act of 2000 requires that annual review of exposure plans reflect changes in technology. It is important to keep our staff safe from blood borne pathogen exposure (BBPE) as well as our patients. CCHMC strategic safety goal supports this: We will achieve and maintain the lowest rates of hospital employee injury and reduce

• ur current rate by no less than 50 percent by June 30, 2015.

7/24/2014 10

What prompted my interest in this topic?

• Perioperative OSHA Recordables Committee, as part of

its ongoing mission to reduce injuries in the OR setting, was responsible for organizing a meeting with an engineering group

• I was invited to attend a safety device brainstorming

session with this medical engineering group

• As a Point of Care (POC) scholar, I created a PICO

question to explore just what was in the literature regarding sharps safety

PICO Question

P Among OR personnel I does the use of sharps safety devices or interventions C versus none O reduce sharps injuries?

Search Strategy

• Keywords: sharps injuries, percutaneous injury, double gloving,

neutral zone, blunt suture needles, engineered safety devices,

• perating room
• Databases: Cochrane Database, Nursing Reference Center,

PubMed, Google Scholar

7/24/2014 11 Findingss

Six articles were found to be most relevant and appraised

• 3 meta-analysis or systematic review(1a,1a,1b)
• 1 qualitative studies (4b)
• 1 cohort studies (4b)
• 1published expert opinions (5a)
• 3 published recommendation statements from

professional perioperative organizations (5,5,5)

Evidence Synthesis

• OR personnel are at risk for blood-borne pathogen exposure (BBPE) due to

sharps injuries and glove tears.

• Surgeons and first assistants have the greatest risk of injury followed by

scrub personnel

• While engineered safety devices are encouraged, few have been found to

be useful for use with suture needles and blades.

• A Cochrane review and others support risk reduction through the use of

double gloving and use of blunt suture needles.

• Five of six articles supported the use of hands free technique (HFT), also

known as the neutral zone.

• One article was supportive of suturing adjuncts(devices for hands free

loading)

• Compliance with the utilization of recommended safety techniques is an

issue ( lack of adherence)

Grade for Body of Evidence

Moderate grade was given for the following reasons:

• Evidence directly relates to recommendation for this

target population

• Has significant benefit to target population as well as

patient population

• Has minimal adverse effects

7/24/2014 12

Most Common Recommendations in Literature

• Neutral Zone also known as Hands Free Zone (HFT)
• Double Gloving (use of indicator glove)
• Use of blunt needles for muscle and fascia

Neutral Zone or Hands Free Zone (HFT)

• Neutral zone is a designated area where sharps can be placed

to reduce the need for hand to hand passing of sharps

• Three-quarters of sharps injuries occur during passing of

devices

• Most injuries are caused by suture needles
• One study reported suture needles (43.4%) scalpel blades

(17%) syringes (12%)

Neutral Zone or Hands Free Zone (HFT)

(continued)

• Modified neutral zone- instrument with sharp passed to

surgeon but returned to neutral zone

• Reasons for non-compliance- we’ve always done it this way,

need for surgeon to look away from field, microscopic cases

7/24/2014 13 Double Gloving

• Wearing an indicator glove(different color) under 2nd pair of

gloves

• Can reduce the risk of exposure to blood as much as 85%
• Corresponding punctures of inner and outer glove rare
• Volume of blood reduced as much as 95% when passing thru

two glove layers

• Barriers to adherence- complaint of lack of dexterity and hand

sensitivity

Use of Blunt Needles

• Recommended for use on fascia and muscle
• Significant reduction of glove perforations reported with use of

blunt needles up to 54%

• Perception that blunt needles more difficult to use
• Alternative wound closure devices are recommended for skin

whenever feasible (tissue adhesives, tissue staplers, adhesive skin closure strips, blunt needles)

Use of Safety Scalpels / Engineered Safety Devices

• Systematic Review/Meta-analysis of 72 citations reviewed,

none were supportive of safety scalpels

• Need to continue to explore better safety engineered devices

(SED)

7/24/2014 14

Under-reporting of Sharps Injuries

• It is reported that 70%-96% of percutaneous

injuries in perioperative personnel are under- reported.

• Don’t want to take the time to go through the post

exposure procedures

• Perception that patient population is low risk

Recommendation

The use of safety devices and/or interventions are recommended to reduce sharps injuries among OR personnel.

Institutional Review Board (IRB) Proposal

A Comparison Study: Does Double Gloving Afford More Protection from Glove Perforations than Single Gloving, Among Operating Room (OR) Personnel?

7/24/2014 15 Why a Study on Double Gloving?

• Anecdotally, at the study site the perception of the OR staff is
• ften that children do not carry as many BBP’s as the adult

population.

• This perception of lowered risk, may add to the reluctance to

double glove as recommended by the literature and professional perioperative organizations.

• This study will seek to address the prevalence of glove

perforations in the pediatric OR setting as well as the perception of OR staff about double gloving.

Hypothesis

Aim 1: To determine the difference in number of perforations in the glove closest to the hand when either single glove or double glove technique is used in procedures where suture needles are used. Hypothesis 1: The number of perforations in the glove closest to the hand will be fewer, when under and outer gloves are worn (double glove technique) compared to single glove technique when suture needles are used.

Null Hypothesis

Aim 2: To describe the perceptions of the OR staff on double gloving Null Hypothesis 2: There is will be no difference in the perception of the OR personnel of the dexterity, sensitivity and comfort of personnel double gloving compared to single gloving.

7/24/2014 16 Study Design

• Liberty Campus OR
• Recruitment letter for staff interested
• Informed consent for interested staff
• Demographic profile (role, years of experience)
• Randomization of staff into two groups: single or double glove
• Study will continue for two months on procedures using

sutures

• Water leak test performed on all gloves
• Data collected entered on RedCap database
• Post-study questionnaire

Variables

• Procedure being performed
• Length of procedure
• Role of the staff member wearing glove
• Number of perforations in the outer glove when double gloving

technique is used.

• Number of perforations in the inner glove when double gloving

technique is used.

• Number of perforations in the glove when single glove technique

is used.

• Location of perforations will be noted- right, left, digit 1, 2,3,4,5,

palm, other

Statistical Analysis

• Assistance from Center for Clinical and Translational

Science and Training (CCTST) with statistical analysis

• Calculated # surgeries over 6 month period
• Determined need to collect 300 pairs gloves from each

group

• Mixed logistic regression will be used to analyze the

differences in rate of perforations between the single and double gloved groups and to determine differences among personnel (RNs, MDs, techs etc.) and procedures. Chi square will be used to determine differences in answers to the post-study questionnaire.

7/24/2014 17 Potential Benefits

• Determine the actual number glove perforations in this

pediatric OR.

• This awareness would allow OR staff to make an informed

decision on double gloving, due to the risk of exposure to BBPs for both the patient and surgical team, should a glove perforation occur.

Final thoughts

Need for sharps safety education needs to begin before reaching the surgical field.

Final Thoughts

Need for self reporting of BBPE

7/24/2014 18 Thank you

• To the supporters of the POC Scholar Program
• Mentors from Center for Professional Excellence
• Nursing Administration
• Liberty Managers
• Liberty Perioperative Staff

Early Speech and Body Movement in Infants with Down Syndrome

Jennifer Bekins, MS, CCC-SLP Speech Language Pathologist Thomas Center for Down Syndrome

Objectives

• To list 2 ways motor skills support early

speech sounds

• To understand the role babbling plays in

communication

7/24/2014 19 Background

• Children with Down syndrome (DS) are

known to have motor and speech delays

• Parents consistently report their greatest

concern is their child’s ability to communicate.

• If motor skills are related to the onset of

speech, then development of targeted interventions is warranted.

Clinical Issue

• Children with DS who experience greater

motor delays also appear to have delayed

• nset of early communication skills

Refined Movement Mobility Stability

PICOT Question

Among infants and toddlers with Down syndrome do motor delays affect onset of pre-linguistic expressive language skills?

7/24/2014 20 Cooing Babbling Development of Expression

Babble

Jargon

Jibber Jabber

First Words

7/24/2014 21 Review of Literature

Inclusionary Terms

• Down syndrome
• Motor development
• Language development
• Speech language

impairment (SLI)

• Concomitant language

and motor development

Exclusionary Criteria

• Articles written before

1995

• Non-English
• Severe to profound

hearing loss

• Children over 2 years

The search yielded 12 articles from the following data bases: CINHAL Plus with Full Text, Medline, Google Scholar, and Psychinfo

Critical Appraisal

A critical appraisal of the literature related to motor skills and delays in early speech revealed 3 articles. The grade for the body of evidence was low.

Synthesis

• Compared with typically developing peers,

children with DS demonstrate delayed motor skills and asymmetries in milestone acquisition.

• In children with DS, emergence of a

neuromuscular link between postural control and rhythmic behaviors, including babbling is

• reported. However, research in this area is

considered pre-experimental.

7/24/2014 22 Rhythmic Hand Banging Recommendation

There is insufficient evidence and lack of consensus to make a recommendation on whether delayed motor skills negatively impacts early speech expression. Further research examining this relationship is warranted.

Implementation

• Development of a research project is underway to

prospectively study the relationship between rhythmic hand banging (RHB) and babbling in children with DS

• Assessment of RHB and vocalization in infants with DS

will be measured at three points:

– Prior to onset of babbling – At the onset of babbling – 1 month post onset of babbling to ensure maintenance of the skill

• It is hypothesized that children with DS who exhibit

delays in the onset of RHB will have later onset of babbling.

7/24/2014 23

Questions and Thank you! Jennifer Bekins Jennifer.Bekins@cchmc.org

Thank You

Cheryl Hoying PhD, RN, NEA-BC, FACHE, FAAN

Senior Vice President, Patient Services

Linda Workman PhD, RN, NEA-BC

Vice President, Center for Professional Excellence and Business Integration

Vice Presidents and Assistant Vice Presidents for Patient Services Directors and Managers at the Point of Care